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Engineered Plan Designs
Tie proven solutions to key benefits
Core of the engineered plan design
Physician Care
Engineered plans want to encourage access to physicians. Even at the highest utilization, they are the least expensive and most effective component of a health plan. A comprehensive network of physicians is crucial.
These benefits are covered at 100% after small co-payments.
Catastrophic Care
These situations are the main reason employees want health insurance. Catastrophic events include all treatments and testing during any inpatient hospitalization. It also includes cancer, cardiac care, or stroke treatments that may be performed on an outpatient basis. These are services where the patient has the least discretion for provider and treatment selection.
Coinsurance for Catastrophic Care is typically covered at 90% after the deductible.
Non-Catastrophic Care
Care and services provided on an outpatient basis are typically identified as non-catastrophic. Many minor surgeries and diagnostic tests are performed outpatient. While all are still medically necessary, the provider, treatment options, and timing are heavily influenced by the participant.
The co-insurance under this category is 70% after the deductible.
ACA Required Preventive Care Benefits
All care and services required to be covered at 100% in network under ACA will still apply in the Engineered Plan.
KEY THOUGHTS
Why does this design work?
Clear Insight has developed a multilevel approach to controlling employee benefit costs. Engineered plans focus on the underlying challenges driving employee benefit costs.
Effective plan design considers prescription drug procurement, participant engagement and positive incentives for valuable participation. Cost shifting to larger deductibles and higher participant out of pocket expenses are not solutions.
The overall claims liability under this approach is lower.
The engineered plan design provides significantly lower deductibles and out-of-pocket costs to employees.
Prescription Drug Procurement
Engineered plan designs offer alternative procurement methods for specific prescription drugs. As the cost of some medication skyrocket, plans need to increase their effectiveness in acquiring these medications with the best terms. Significant savings to both the plan and the participant can be achieved with these programs.
Participant Engagement is Key
Healthcare is complicated. Solutions are not always simple.
Engineered plans are more involved than traditional PPO plans. They have been created by studying the utilization patterns and specific behavior trends of participants using the healthcare system. Participants need to be involved in the costs and selection of the healthcare services they use. The more your employees understand the plan design, the more effective it will become.
Flexible Employer Funding Options
Employers can select minimum premium funding or a self-funded captive approach. Sometimes employers prefer to fund their health plan similar to a fully insured plan. The minimum premium approach allows employers to set a maximum liability for the plan year. While the self-funded option offers access to captive reinsurance options.